Title: Does Hospital Price Competition Influence Nurse Staffing and Quality of Care?
1Does Hospital Price Competition Influence Nurse
Staffing and Quality of Care?
- Julie Sochalski, PhD1
- R. Tamara Konetzka, PhD2
- Jingsan Zhu, MBA1
- Joanne Spetz, PhD3
- Kevin Volpp, MD, PhD1,4
- Academy Health
- June, 2005
- 1 University of Pennsylvania 2 University of
Chicago - 3 University of California at San Francisco 4
Philadelphia VA Medical Center
2Introduction
- Over past 20 years hospitals shift from competing
on quality/amenities competing on price. - Evidence that price competition rate of
increase in hospital costs, profits
efficiencies or lower quality? - Examine impact of price competition on one
feature associated with hospital quality nurse
staffing.
3Nurse Staffing Patient Outcomes Relationship
- Cross-sectional studies over 3 decades show
higher nurse staffing associated with reduced
mortality. - Recent longitudinal study found increases in RN
staffing linked to lower mortality, with
diminishing returns. - Most studies rely on hospital-wide measure of
nurse staffing which may obscure relationship.
4Hospital Responses to Price Competition
- Hospital personnel increased from 1980s to early
1990s. - RNs increased commensurate with volume and CMI
while other nursing personnel declined. - Spetz (1999) found HMO penetration was not
associated with RN staffing through early 1990s.
5In summary
- Substantial gaps in understanding of nurse
staffingquality relationship. - Rely on crude staffing measures to explore
relationship. - Lack information on current hospital responses to
price competition. - 1999 California passes AB 394 to establish
minimum nurse staffing ratios.
6Research Questions
- Are changes in nurse staffing levels associated
with patient outcomes? - What hospital and market features are associated
with staffing changes and thereby outcomes?
7Study Design
- California acute care hospitals, 1991-2001
- Three AHRQ inpatient quality indicators
- 30-day mortality for AMI, stroke, and hip fracture
8Data
- Californias Office of Statewide Health Planning
and Development (OSHPD) discharge data from 1991.
- OSHPD annual disclosure (financial) data
1991-2001 - State death certificates 1991-2001.
- Sample
- Hospitals n 421 short-term acute hospitals
- (non-federal, non-Kaiser)
- Patients
- AMI n 352,536 (15.5)
- Stroke n 592,651 (14.1)
- Hip fracture n 276,628 (5.3)
9Key Study Variables
- Nurse staffing
- RN, LVN, Nurse Aide
- Nursing productive hours per patient day
- Acute medical-surgical units
- Market factors
- HMO penetration for hospital market area (fixed
radius) - High vs. low competition market areas
10Control Variables
- Age
- Gender
- Race
- Ethnicity
- Expected source of payment Medicare, Medicaid,
uninsured, private - Elixhauser comorbidities
- Hospital case-mix index
- Year dummies 1991-2001 (1991 is reference)
- Hospital fixed effects controls for
time-invariant hospital and market factors
11Model
- Generalized linear model with hospital-level
fixed effects time fixed effects
Model 1
Model 2
12Hospital Summary Statistics
- No. of hospitals 421
- Avg. beds 192
- Urban 88
- Teaching 18.7
- Ownership
- Non-profit 52.7
- Government 20.7
- For-profit 26.6
- Avg. CMI 1.114
13Change in CM-adjusted RN medical-surgical hours
per patient day, 1991-2001
75th
25th
14Effects of nurse staffing on 30-day mortality
Model AMI Stroke Hip Fracture
RN -0.004 (0.001) -0.002 (0.001) 0.002 (0.001)
LVN -0.003 (0.002) 0.0004 (0.001) 0.0008 (0.001)
Aide 0.001 (0.001) -0.0002 (0.0007) -0.0001 (0.0007)
RNbaseline 0.0004 (0.0002) -0.0001 (0.0001) -0.0004 (0.0003)
p lt .05 p lt .1
15Effects of price competition on nurse staffing
HMO Penetration 2.479 (0.696)
HMO PenetrationHHI -3.192 (1.245)
p lt .001 p lt .01
16Caveats/Limitations
- Changes over time in DRGs, coding, zip codes (but
smoothed/corrected to the extent possible) - Limited to California generalizable to other
states? - Limited to mortality generalizable to other
quality measures? - Are there thresholds to staffing-quality
relationship?
17Conclusions
- Extent to which changes in RN staffing levels are
associated with lower mortality varies by
condition. - Increasing managed care penetration is associated
with higher RN staffing except in most
competitive markets. - Limiting the number of patients per nurse may
improve quality outcomes.